Pulmonary Veins to Left Atrium Cycle Length Gradient Predicts Procedural and Clinical Outcomes of Persistent Atrial Fibrillation Ablation
Background—Rapid pulmonary vein (PV) activity has been shown to maintain paroxysmal AF. We evaluated in persistent AF (PsAF) the cycle length (CL) gradient between PVs and the left atrium (LA) in an attempt to identify the subset of patients where PVs play an important role.
Methods and Results—97 consecutive patients undergoing first ablation for PsAF were studied. For each PV, the CL of the fastest activation was assessed over 1 min (PVfast) using Lasso recordings. The PV to LA CL gradient was quantified by the ratio of PVfast to LA appendage (LAA) AFCL. Stepwise ablation terminated AF in 73 patients (75%). In the AF Termination group, the PVfast CL was much shorter than the LAA CL resulting in lower PVfast/LAA ratios compared to the Non-termination group (71±10% vs 92±7%, p<0.001). Within the Termination group, PVfast/LAA ratios were notably lower if AF terminated after PVI or limited adjunctive substrate ablation compared to patients who required moderate or extensive ablation (63±6% vs 75±8%, p<0.001). PVfast/LAA ratio <69% predicted AF termination after PVI or limited substrate ablation with 74% positive predictive value and 95% negative predictive value. After a mean follow-up of 29±17 months, freedom from arrhythmia recurrence off-antiarrhythmic drugs was achieved in most patients with PVfast/LAA ratios <69% as opposed to the remaining population (80% vs 43%, p<0.001).
Conclusions—The PV to LA CL gradient may identify the subset of patients in whom PsAF is likely to terminate after PVI or limited substrate ablation and better long-term outcomes are achieved.
- cycle length
- persistent atrial fibrillation
- atrial fibrillation arrhythmia
- pulmonary vein isolation
- pulmonary vein
- cardiac electrophysiology
- Received July 19, 2013.
- Revision received March 16, 2014.
- Accepted April 8, 2014.